Thinking about looking into speech, occupational, or physical therapy for your child?
It’s possible that your insurance plan may cover these services (most health insurance plans cover speech, occupational and physical therapy services). And because paying privately for your child’s therapy can be pricey, it’s a good idea to look into this first.
Not to worry! Here’s a breakdown of the need-to-know insurance terminology and a basic roadmap for using insurance to cover your child’s speech, occupational, or physical therapy services.
Step 1: Be proactive.
It’s important to contact your health insurance provider before your child begins therapy. This can help ensure that you aren’t stuck with an unexpected bill later on.
You’ll also know if your insurance will only cover therapy at a certain type of facility, before you schedule your child’s first appointment.
Step 2: Ask the right questions.
Here are some specific questions to ask:
- Does my plan cover speech/physical/occupational therapy for my child?
- Will my plan cover this therapy in any setting? (for example, private practice (office), outpatient clinic, or teletherapy)
- Are there any specific conditions or limitations for coverage? (some plans include or exclude certain medical diagnoses for therapy coverage)
- Does my plan require an authorization for services meaning does my plan need to pre-approve services before starting?
- What is my coverage for both an initial evaluation and for ongoing therapy?
- Does my plan cover a specific number of therapy visits or appointments over a date range? (ex: 30 speech therapy visits per year or for a period of 6 months?)
- If my child is approved for a certain number of therapy visits, are these visit combined with other therapies (speech, occupational, and physical therapy?
- Do I have a copay or coinsurance for these services?
Step 3: Know the terminology.
In-network: A provider or health care facility that is contracted as part of your insurance plan’s network of providers. Services have been negotiated at a discounted rate.
You’ll still be responsible for any copays, coinsurance, or deductible amounts, but going to a therapy facility that is in-network with your insurance provider will be billed at a lower cost. And your deductible may be lower if you use an in-network provider.
Out-of-network: A facility that does not have a contract to participate in the insurance plan’s network of providers. Depending on your plan, services at a therapy facility or with a therapist who is out-of-network with your insurance can either not be covered at all or only partially covered.
Before you schedule your child’s first therapy appointment, you may want to check to see whether the therapy company/facility is considered in-network by your insurance plan.
You can typically see this through your insurance company’s website. Some therapy provider websites may also list insurance networks that they are contracted with.
Claim: A claim is a request for payment submitted to your plan for services provided. Claims can take anywhere from a couple of weeks to a couple of months for an insurance company to process. In-network providers are typically required to sumbit claims on a member’s behalf. However, if you use an out-of-network provider, they may only provide you with a superbill (defined below) that you will have to submit on your own for reimbursement of healthcare expenses. Some out-of-network providers may submit claims on your behalf but they may require payment upfront for services and direct any reimbursement by your plan to go directly to you.
Superbill: A superbill is a statement from your provider detailing the healthcare services you received and related costs. This is what you would submit to your plan for reimbursement.
Copay: Also known as a “copayment”, a copay is a fixed dollar amount that you are responsible for paying for each visit, as determined by your insurance plan. The dollar amount of a copay varies depending on the service. Even if you pay your copay, you will still owe your deductible if it has not already been met i.e. paid.
In most cases, you’ll have to pay the full cost of a service out of pocket until you meet your deductible. Then, you’ll be responsible for the copay or coinsurance, defined below, for each service your child receives.
Coinsurance: The percentage of a service that the insurance policyholder is responsible for paying. This is similar to a copay. The difference is that a copay is a flat dollar amount, and the coinsurance is a percentage of the total cost.
Some insurance plans, for example, might pay for 75% of a therapy service so your coinsurance would be the remaining 25%.
Deductible: This is the total amount of money you have to pay towards covered services before your insurance plan starts to pay. The amount accumulates over the year as you pay towards the deductible amount that has been determined by your insurance provider.
Exclusions: A provision within an insurance plan that eliminates coverage for a certain service. In the case of therapy, find out if your insurance excludes coverage for certain diagnoses, like a developmental delay.
Authorization: An authorization is a requirement by certain health plans that a member obtain pre-approval for a health care service before the care if provided. Not all plans require authorizations but if you begin services without one in place, your plan can deny claims until one is obtained.
Gap Exception: A gap exception is a request to pay in-network benefits for a member when using an out-of-network provider. Typically, plans only grant these exceptions if they have a “gap” or deficiency in their network coverage for the specific service a member is seeking. Many times, they review if any in-network providers exist within a 30-miles radius of a member’s home. If none are available, then they may grant a gap exception.
Good Faith Estimate: With the No Surprises Act that went into effect on January 1st, 2022, health care providers are required to provide all patients who either do not have insurance or are paying out-of-pocket for services, i.e. self-pay, an estimate of the bill for services before they provide care. For more information on the No Surprises Act, you can visit: www.cms.gov/nosurprises
Step 4: Get started with therapy
If you plan to use a therapy provider you’ve found to be in-network with your insurance, obtain a script for a Speech, Occupational, or Physical Therapy evaluation from your child’s pediatrician. Then call the therapy provider to schedule your child’s initial evaluation. You’ll provide the therapy facility with your insurance information.
As you submit claims for appointments like the evaluation and weekly therapy, you’ll receive an Explanation of Benefits (EOB) from your insurance provider.
The EOB is not a bill, but will break down the costs that the therapy provider charged, how much the insurance plan covered, and the amount that you are responsible for. It will likely include information about your deductible as well.
If you have concerns about your child’s development, he or she may benefit from specialized services from a speech-language pathologist, occupational therapist, or physical therapist. An initial evaluation can help determine what difficulties your child is having. Ongoing individualized therapy can include techniques and activities to help improve these areas.